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Hello, everyone. Welcome to the year for academic provision tutorials, which is a week long series that covers all the specialties rather than to the Edinburgh medical school curriculum. We're covering cardiology and respiratory today and we're very lucky to be joined by Salma, 1/5 year medical student who will be teaching the session every two. You Salma. Thank you very much Lucas. Um Yes. So as Lucas was saying, it's cardiology and respiratory um sessions quite focused on just going through MCQ questions and sort of discussing around them any little pointers I can give you from what I remember from last year. Um and we'll try and go through them. There's quite a lot to get through. So we'll just try and get started and get through it as quickly as we can. Um Right. So first quiet, I'm going to start off with a case and the first question. So 65 year old Scottish man who has recently been diagnosed with type two diabetes, sends a G P for a checkup. He's particularly worried about his BP because things have been stressful at home regarding his wife's health and he missed his last appointment at the diabetes clinic. The G P takes a BP reading which is 100 and 44. Over 92 he takes Metformin where she's tolerating. Well, he smokes five cigarettes a day. Does not drink alcohol. His father passed away from a heart attack aged 80. And the question is, which of the following is not a recognized risk factor for hypertension. So I try to just get the pull up. I can give you a couple of seconds. Sounds for that one. Okay. So the correct answer for this question was stress actually. Um uh I think that's sometimes a little bit of a misconception, but stress is actually not a recognized risk factor for hypertension. Um Alcohol smoking and high cholesterol are I think probably uh fairly obvious and then impair, impair intrauterine growth is actually a risk factor because it affects kidney development and adaptive BP mechanisms in the long term. So that tends to be a risk factor. So a little bit of a trick question, but uh just a useful point to keep in mind. So next question, same case. Um What is the most appropriate first step for the repeat to take with this patient? Can just a couple of seconds. Answer that one. Yep. And as most of you put the correct answer is be arrange ambulatory BP monitoring. Um I think we have a slide for that. So to confirm hypertension, you want to be using ambulatory but BP monitoring, I think when you get that kind of question, it's very easy to straightway, prescribe a drug. Uh think of something to do for management. But when the BP is within a certain range, so we've got the different grades of BP there from 1 40 to 1 60. when it's in that kind of range, the first thing you want to be doing is checking the ambulatory BP. And the reason for that is that will help you to confirm whether the patient truly has hypertension because it could just be um high reading, for example, in, in clinic that can happen and that's quite commonly seen with patient's. So it's always useful to do the ambulatory BP before you start prescribing drugs and things. Um and we just got the some. So if it's grade one or two, you want to do the ambulatory BP monitoring and diagnose hypertension at that point, for grade one, it would be 100 and 35 250. And then anything over 100 and 50 would be great too. And if in clinic, the measurement is over 100 and 80 and at that point, you don't wait around, you start treatment immediately. So that's where you start to prescribe the drugs and things like that. Um So yeah, so this is just another uh diagram which just kind of illustrates that kind of point. So um hum as we said, for under 100 and 40 you want to offer the monitoring, uh ambulatory BP monitoring is the first choice thing that you want to do. Um The other one that you can do is home BP monitoring. There's a similar thing but it's just not as um um not as sort of accurate. Um And another question that can come up with this kind of thing is when the BP tends to be on the higher side. Uh One of the things you want to be doing is investigating for target organ damage. So that's things like you might want to investigate the kidneys. Um The eyes looking for papilledema, which can signify that there is some end organ damage, um neuropathies, things like this. So you want to be asking the patient's about that kind of thing and just making sure that there is no end organ organ damage. And at that point, if you were to come across something, you would start considering giving them drugs or treatments straightaway similarly um to if it was a great three hypertension. Um And I think we'll get onto specific drug drugs and things in a second. Another thing to keep in mind is that offering lifestyle advice, if, if it's a patient who's um done the ambulatory blood pressuring BP monitoring and they've come back stage one or stage two, um or specifically stage one generally. And the first thing that you want to be doing is offering lifestyle advice. Um So things like keeping a healthy diet, exercising, things like that, things which are simple um should be high up first line management options that you give the patient. Um So yeah, so moving on to some drugs. So anti hypertensive drugs, you start them for great to hypertension, which you said it was over 100 and 50. Um And if you get great a grade one hypertension plus diabetes target organ damage, cardiovascular disease, renal disease, or uh 10 year cardiovascular risk of great and 10% which you work out using the Q risk score. And if you have any of those things, you want to start considering and using drugs. So question three for this one, same case, it's decided that antihypertensive therapy should be started, which is the most appropriate first line therapy for this patient. Mm She got a pool. It is go a couple of seconds down to that one. Yep. And as most of you have gone for is the correct answer. So, Lisinopril, um generally, in most cases, the first thing that you want to start off with is um is an ace inhibitor for most people. Um This is a useful kind of diagram to keep in your mind. Um So if the person has diabetes straightaway as an ace inhibitor that you want to be given them or an angiotensin receptor blocker, if they're aged over 55 or their of black African or Africa Ribhi in origin, then a calcium channel blocker would be the first line treatment. Um That's just useful thing to always keep in mind when you're answering these kind of questions, look at the patient's age, look at their ethnicity that's given and understand if they have diabetes or not because that will change the 1st 1st line management and then from there onwards, step to generally, you're adding the other type of uh anti hypertensive that you haven't already added. So with the ace inhibitor, you add the calcium channel blocker and the other way around. Uh if the, the Castle channel blocker was added, first, can also add fact that I'd like diuretic at this point. Uh Another option for both. Um And then step three would be to have all three of those together and then moving on to step four. Um, you'd want to, first of all, you want to look at and confirming that the BP is still high. Um And you'd wanna assess for adherence at this point because you've given quite a few drugs, quite a few medications and most patient's that should to, should do the job. But if not, then you just want to make sure that they're taking their medications properly. Um And after you've decided that's all adequate, then you have two options for what you do next. Um, you look at the blood potassium level and if it's less than 4.5, you'd give a potassium sparing diuretic. So something like spironolactone and if it's greater than 4.5, you give an alpha blocker or a beta blocker. Um This is quite a common exam question. So I definitely try to learn this and keep this uh sort of diagram in your mind when it comes to this kind of thing. Um Side effects, um quite a few side effects, but the main ones that tend to come up a sin. Him, bitters are dry cough is quite characteristic. Um And calcium channel blockers remember the demo? Um There's a few other ones listed there. I would say the laser to kind of main ones that you see coming up quite often. And yeah, you should be aware of things like hypokalemia and things like that. But the cough, the dry cough and the edema, I think of them in to, to be aware of um question for. So same patient again, what is this patient's uh target systolic BP and they'll put pull up. Okay. So, um for this question, the correct answer is under 130. So options see there. Um And for people with diabetes, that's just the systolic BP um target for people in diabetes. So that's just useful to keep in mind. And now moving onto malignant hypertension, um, shouldn't, doesn't come up as much, but just always useful to keep in mind. Um, with malignant hypertension you'd have very, very very high BP and this would lead to rapidly progressive end organ damage and that's a medical emergency. So, signs of symptoms of this kind of thing are a very sudden increase in blood pressure. But blurred vision headache, shortness of breath decrease in your in a couple of demo weakness or tingling in the legs and seizures. So if you see a patient really high BP and some of these symptoms, you want to keep that in mind. Uh Try to uh I just realized that that that is malignant hypertension and you need a controlled reduction of BP bed rest using anti hypertensives and things like that. Um I think that is the last of hypertension. So moving on to E C G S now. Um so you're a medical student on the cardiology ward practicing how to read the CGs F I to hand you the C G of a 70 year old, a symptomatic man to interpret and looking at this E C G, which of the following is the correct diagnosis. Okay. Pull up again. Give you some time to have a look at that and answer that one. Okay. If you have any questions at any point, just pop them into the Trat and either Lucas for myself or, or try and answer them for you. Mm Okay. So the answer for this one I believe is right bundle branch block. So that was the option D. Um So write down the blood flow is a useful thing to uh keep an eye out for. Um it's pretty characteristic on E C G s and when you see it, it's uh pretty much a slam dunk um answer. Um a very useful pneumonic to try and remember is William Marrow. So what you typically see in right bundle branch block is in lead V one, you typically see the M in marrow and then in V six, you would see the double, you sometimes it's a bit hard to see to make out, but you just keep an eye out for that. You should uh should, should be getting those right and, and the opposite is true for um and for a left bundle branch block. So you'll be seeing the W in V one and the M in V six. Um So right bundle branch block is just caused by deep polarization of the right ventricle being delayed and the left ventricle depolarizing normally. And that is what results in the kind of M and W that you get, which is a splitting of the QRS complex. Um So just always keeping keep an eye out for that. And um it's um can be a little bit tricky to see, but if you look closely, you should be able to make those out. Um some causes of bundle branch block. So left bundle branch block tends to be hypertension, coronary artery disease, aortic valve disease, cardiomyopathy, right bundle branch block can actually be normal as well in some people. Um But coronary artery disease, once again, congenital heart disease and, and right ventricular problems such as hypertrophy or strain, you can lead to a right bundle branch block on an E C G. Um Typically if you see a bundle branch block on an E C G, you do and it wasn't there before um or a left bundle branch block that wasn't there before You should be considering an M I. It could be a possibility. So that's also a good one to look out for because that can help you get to the correct diagnosis if you see that on an E C G. And so uh next one, you review the E C G of 75 year old, a symptomatic manus over an M I two years ago. And what does the E C G show pull up in? We've got some uh questions here. Why are left bundle branch block classed as a stemi? Um If I'm honest, I'm not entirely sure but like the pathophysiology behind that. But if you do see a left bundle branch block on uh E C G that wasn't uh there before, you should be straight away considering the stemi and that is the correct diagnosis. Um What actually is the bundle branch block in terms of where it is in the heart? So, bundle branch block is generally, it's caused by um the impulses traveling from the nodes to be uh sort of misfiring and that kind of uh or being blocked. And that means that the ventricles aren't depolarizing correctly. And that's why you get the splitting of the QRS complex is and the uh kind of typical signs that you see with it. Um But yeah, I think the main thing when it comes to uh bundle branch block is just keep an eye out for it on the E C G, use William Marrow to try and identify it. And if you see it, um consider if an MRI is likely or not and what the possible causes for it could be like we went through here um useful to keep some of those in mind. Obviously, coronary artery sees the big one and it's probably the most likely one in all of these cases, but just based on the uh information they tell you about the patient, just try and keep it in mind and should be able to get through those kind of questions quite well. Um And the BP targets is an age under 80 years, clinic BP 140. Um I'm not too sure. I don't know the exact targets off the top of my head. Um I remember last year we had, I had this problem as well. Uh Just very varying places telling us slightly different targets, I would say whatever the nice guidelines state currently are the ones that you should be using. So if that is what stated in there, then go with that. I haven't looked at them myself this year, unfortunately. So I'm not entirely sure. But if that's what you've been taught untold, then, um, that should be correct. And, um, I'll get the pull up for the C C G here. And yeah, the answer to this one is B second degree heart block type one. Um The reasons for that is you can see it's usefully uh circled at the bottom there on the rhythm strip. So you can see the pr intervals between uh complexes are getting longer by each one. And eventually there's a P wave that is not conducted. So whenever you see that, that straightaway, second degree heart block type one, um so heart block is just a useful thing to keep in mind, first degree heart block A V conduction delay. So the pr interval is uh normally elongated over 0.2 seconds and that's normally a symptomatic patient's wouldn't even know that they have that. Um it tends to be caused by impaired conduction and the A V nose itself and it can just be physiological um second degree heart block. So that's where you start to get the drop beats. So as it was the case in that E C G before, it was more bits type one, which is the progressive lengthening of the pr and that's leading to drop beats. Um And then you can have more bits type two which the pr interval is consistent but some of the P waves aren't conducted. Um And that one, uh more bits, type one can also be physiological. Um uh Type two normally isn't. Um And it tends to be caused by uh disease of like the hispa Kinji fibers um in the heart and you have the risk of asystole. So you don't want to miss that one third degree heart block. So that's a complete block where you have complete dissociation between the atrioventricular node. Um uh The normally the ventricular activity is maintained by kind of escape rhythms from the ab node to the uh to uh sorry from the ab nose or hiss and you kind of get narrow. Um QRS complex is because of that and um I'm just trying to remember from some head from, from the Aviane order his to the distal per Kenji fibers. Um So you would get a narrow complex or abroad complex. Um if that makes sense and it kind of produces a slow regular pulse. Um A few different causes of third degree heart block can be congenital or acquired from a variety of conditions. Um It's I think idiopathic fibrosis, am I um trauma and certain drugs as well can cause that kind of thing? So, just always useful to keep that in mind. Um So this is another E C G. Um A 70 year old lady, complaints of palpitations and feeling dizzy or E C G is shown below. Think it should be shown again here. It's a bit small. But what is your diagnosis of this one? Um But poll uh and I realize it's kind of got the answer down there at the bottom anyway. But uh yeah, I can go back to the bigger one. Yeah. Mhm. So, yeah, as most people put this is atrial flutter um with atrial flutter, I'll go back to the big one. If you look at the rhythm strip, you get that classic Sawtooth appearance. So as soon as you see that on an E C G, you know, that's atrial flutter. Um I think we uh it's no slide on it. Um Yeah, so just keep, keep an eye out for that. It's very characteristic. And as soon as you see that, um it's pretty slam, pretty much slam dunk question and yeah, the answer is kind of written there I realized afterwards. Um But yeah, as it says caused by a large reentry circuit and the atrial rate tends to be 300 BPM. So, yeah, I wanna, I wanna picking that one up. Um Case too. Um A 60 year old lady presents to the G P because she's even feeling lightheaded over the past month, complains of being more breathless recently and sometimes feels her heart beating in her chest. She denies pain or ankle swelling. One examination. She has an irregularly irregular pulse and her BP is 100 and 62 over 100 heart sounds are normal. No other medical history practice nurse obtains in E T G, which is part of, which is shown below. Um, given the likely diagnosis, which of the following is not a recognized cause of the condition. Okay, I'll give you a couple of seconds to think about that one. So the answer for this one is a stroke. Um, uh, all the other ones are causes. Um, So I think hopefully you guys all picked up that this is a F um pe pneumonia, thyrotoxic courses, alcohol excess, they're all causes of untreated af where as uh stroke is a consequence of uh um sorry, a consequence of untreated af um So that's why when you, when patients have a f you want to be giving them anti coagulation. Um So if a patient presents to you with palpitations, discipline of TV, lightheaded chest pain, always want to be considering atrial fibrillation as a possibility uh in the stem of questions. If it says irregularly irregular process, you bring pretty much guarantee that they're probably talking about atrial fibrillation there. So, always useful to keep that in mind. A few different types of af paroxysmal, we get intermittent episodes for less than 70 days. So uh seven days, sorry, a symptomatic well tolerated. So there's no real need for treatment. If, if there is a need for treatment and beta blockers can be used. Um If they're persistent, so prolonged episodes, you're going to have to start considering cardioversion. So options for that would be trying to do some rhythm control with electoral electrical cardioversion or with IV flecainide or IV amiodarone. And then following that patient would be on anti coagulation for at least three months. And if they've got permanent af then we want to be looking at rate controlling them and use that to do that. You use digoxin beta blockers for a pill mill or dilTIAZem. Um um Oh yeah, just a little point about IV flecainide. Um You want to making sure that when you use IV flecainide, it should be used in patients with no structural heart disease. Um And I've you amiodarone if patient's do have structural heart disease or stomach heart disease. So that's just a useful thing to keep in mind. So that could be something that comes up in questions to kind of throw you off. So always useful to keep that in mind and case to. Um again, the same lady I believe. Um So on examination. Yep. Come through all of that. So what is our Chad Vask score? Um I'll pull up for that. I think on the slide that's listed. I don't know. I'm sorry, that's a different question. That's fine. A couple of seconds down to that one. So yeah, that one's pretty split between C and D. So I think for this question, the answer is actually d so we said Chad score of three. So Chad score is definitely something worth learning. Keep that in your mind, it will um pretty much guaranteed to come up whether it's directly asking you to work outpatients, Chad Vask or, or to use that in a situation to guide management and things like that. So it's pretty easy to remember once you get started with that. Um So sees for congestive heart failure and you score one point for that hypertension one point age. So if they're between 65 to 74 they get one point. If they're 75 plus two points, uh diabetes, one point, previous stroke or T I A two points, vascular disease, one point. Um oh and then yeah, age again, they're 65 74 1 point. And if they're female, that's one point as well. So if we look at our patient here, she had no cardiac uh no congestive cardiac failure. She had hypertension, her age with 65 no diabetes, no previous stroke or stroke and she was female. So she would score three for that. Um And of course, remember what the point means. So zero point, no prophylaxis and that's all good. One point you want to be considering anti coagulation at that point. So for a female, you give aspirin and for a male, you give an oral anticoagulant and um if they're scoring more than two points, it's guaranteed or all anti coagulation will be needed. Um Yeah. Okay. So next question, which of the following drugs will be most effective for rhythm control. So we just went through that, just stick the pole up and yeah, as most people put um flecainide is, is the correct answer. Um So the uh the other drugs are for rate control. Um It's always useful to keep in mind the difference between which ones are for rhythm and which ones are for rate control. And then obviously Warfarin, there is an anti quad Diovan. Um So moving on to the next case, um A 68 year old woman presents the G P with a four week history of gradually worsening central chest pain. When she's out walking her dog, she feels breathless and lightheaded. So as to stop until she feels better to continue, she's longstanding hypertension and type two diabetes. She's on Lisinopril, Metformin and Simvastatin. She continues to smoke 10 cigarettes a day and as a B M I of 28 given the likely diagnosis, what is the most appropriate management for this patient? It's quite a lot written down there. Um I'll start the pole and I'll read through it. So option is call 999, you suspect in ACS administer aspirin and G T N Spoerri. Option B provide lifestyle advice and referred to smoking cessation team review in four weeks, provide lifestyle advice, increased dose of Lisinopril prescribed aspirin, 100 mg and GTM Sperry referred to smoking cessation advice, all Prolol. Um and option E provide lifestyle advice Aspirin Soccer law and G Tien's Berry, we'll wait for a few more answers. All right. So the correct answer for this question is e so providing lifestyle advice, prescribing Aspirin, uh Bisoprolol 10 mg in G T N Sperry. So hopefully you guys worked out the diagnosis was angina in this case, rather than an MRI or an acute Coronary syndrome. Um And so that's why the answer wasn't because it says the patient feels the kind of pain coming out when she's walking her dog. So on exercise on exertion, um it wasn't a slide for this. But um yeah, so for the nice guidelines suggests that you want to offer a short acting nitrate. So something like a G T N spirit for preventing and treating episodes of angina. Uh you want to be considering aspirin, 75 mg daily for people with stable angina and obviously, with aspirin, you want to consider the risks of bleeding and any Cold War Regis's you might have and then you'd um consider adding an ace inhibitor uh for people with stable Angina and diabetes. Um so that could have been um option here, but I think she was already on Lisinopril. So she was already on the ace inhibitor. And then on top of that, you want to offer either a beta blocker or a calcium channel blocker as first line treatment for stable angina. So the things that you want to be remembering to do, obviously, lifestyle advice GTs for a aspirin beta blocker or a beta blocker, calcium channel blocker and an ace inhibitor if the patient has diabetes. So quite a list of things, but just always useful to remember when it comes to Angina, move on to the next question. So the same patient three months after a visit to the G P, um 68 year old woman presents to the any with crushing central, central, crushing chest pain, raising it, radiating into her neck with nausea and vomiting. Um started when she and her husband were walking to the shops and it wasn't relieved by her G T N spray. And her husband admit she has not been very good at taking the GPS advice or her medications. You take bloods including cardiac enzymes and the 12 lead E C G you administer aspirin, morphine, 10 mg IV and medical promotes 10 mg. IV. Her E C G is shown below. What is your initial diagnosis? I hope you guys can make that might need to zoom in a little bit. It's quite faint. I'll get pull up. Yeah. Give you some time to go through that one. Yep. So as most of you put and the answer is d um an anterior stemi. Um so you can see it's quite faint but if you can just make out um it's quite an extensive interior stemi. Uh The E C G shows uh ST elevation in leeds V 1 to 6. You can see in all of those and also in A B L. Um, there's a little bit in there. Um, sometimes with stem is what you get is like a reciprocal ST depression in aVF and um lead three and you can kind of make it out a little bit. Um It's obviously a bit faint there, but I think there is a little bit there. So, yeah, next question, what is the most appropriate, next step in her management? Don't get pulled up. Um Someone's asked about the reason for giving aspirin. So, um I think the main reason for aspirin, um normally it's um for sort of anti coagulation purposes and um stable angina. I'm not entirely sure the exact reason. Um I'm not sure if Lucas could help out with that one. Um But it is something that you want to be giving in and trainer and considering the kind of and the risks that are associated with bleeding when it comes to that. Um Yeah. Um So yeah, as most people have put for this question, the answer is d uh primary PCI. Um uh Yeah, so she's had an M I hear obviously um something that you want to keep them in mind. I don't think it's said in the question. Um No, I didn't give a timescale. So you want to make sure that she's within the timescale for getting the PCI intervention. Um uh Normally it says that in the questions, but just keep an eye out for that. Um So moving onto case four um question 1, 72 year old inpatient is complaining of breathlessness and a productive cough of frothy sputum is tachycardic has no as a narrow path pressure on auscultation, you know, tic gallop rhythm and by basal crepitations which of the following is the most appropriate immediate management. Um A few options there, we'll get pull up. Mhm. So yeah. So as most people put, be so sitting the patient upright, giving them oxygen, getting IV access and giving IV morphine and IV frozen, right? So I think you should be, you know, um So uh pretty classical presentation of heart failure. Um got breathlessness and the productive cough. So suggesting um possible fluid fluid overload, tachycardic and a narrow pulse pressure. And you notice a Bible crepitations in the gallop rhythm. So that again is suggesting that the patient's fluid overloaded and um heart failure would be something that you consider as a differential. So, of course, you want to be sitting them upright, giving them oxygen. So that will help with their breath, breathlessness. Um Diamorphine if they're, you know, pain and I be furrow, samide um to help offload some of that fluid um question to which of the following or not indicated in the management of chronic heart failure. Mm So a little bit split on this one between A and B. Um So the correct answer for this one is A um and the reason for that is verapamil should be avoided because it reduces cardiac uh contractility. So generally, and chronic heart failure, you want to avoid that. Um hydrALAZINE. Um So hydrALAZINE and nitrate, uh it's um indicated first line if patient's are intolerant to an ace inhibitor or an angiotensin receptor blocker. Um And second line, if the systems uh symptoms cannot persist, um Option C can start and that's an ARB. So that's the first line option for chronic heart failure. It's Viron elect on its second line. So that's something that you do want to be giving and bisoprolol, it's also first line along with the ace inhibitors. So verapamil just keep that in mind, it tends to be a drug that you want to use carefully when it comes to um cardiac conditions and things like that because of interactions and things. And one thing to always keep in mind is don't give verapamil and a beta blocker at the same time. Just yeah. Um So looking at heart failure, heart failure management and so um if you have heart failure with preserved ejection fraction, you kind of just manage that by managing other conditions such as the hypertension, um and diabetes and things like that. And if we've got heart failure due to left ventricular systolic dysfunction, so as I said, first line ace inhibitors and beta blockers. Um and then after that, we're gonna start considering other options. Um it gets a little bit complicated because that's uh requires specialist assessment at that point. It's always used to just to remember the first line for heart failure, ace inhibitors and beta blockers. Um Once you go past that, then you're considering some other drugs. So, so it's just hydrALAZINE, um spironolactone on and perhaps adding an ARB at this point as well. Um So yeah, but the for heart failure just keeping in mind the first line, it's probably the most important um case question three. Um which of the following couple of complications is unlikely in a patient being treated for a chronic heart failure? Mhm. Um This is a little bit of a tricky question. So I'll give you some time. Yeah. All right. So the correct answer in this one is actually see increased clotting factor production. Um And the reason for that is a um synthesis of clotting factors is likely to decrease in chronic heart failure. Um because uh chronic heart failure leads to venous congestion which affects uh the functioning of the liver. So, liver function will be reduced. And of course, we know one of the functions of the liver is to produce clotting factors. So that would decrease, not increase. Um Looking at the other options. F and I think uh fairly obviously, it occurs in 20% of patients with heart failure. So it's something that can happen and other arrhythmias are also possible as well. Um mild jaundice. So that's the same reason as the uh liver function, um or sorry as the clotting factors being decreased. Um So, uh with chronic heart failure, the liver function would be impaired. Um So you could expect to there to be some mild jaundice in the patient. Um hypokalemia and hyperkalemia. Um So, they're, they're both actually possible in chronic heart failure, hypokalemia, um could be due to some of the diuretics um that you're using. Um and that could or it could also be due to hyperaldosteronism which causes the which is caused by the activation of the ras system. Um and also impaired metabolism of hormones. Um Again, due to the liver function being decreased and hyper claim eah that can be a consequence of the drugs once again. So spironolactone, um it is a potassium sparing diuretic. So it can lead to more potassium being retained hyperkalemia or if something to keep in mind, case 5, 65 year old woman is admitted with dyspareunia, fever and malaise on examination. You know, it's a temperature of 38.1 pansystolic murmur heard loudest at the apex. There are no stigmata in the hands. You send routine bloods, blood cultures and chest X ray. She has recent notes on track from an admission 30 days ago for coronary angioplasty. These notes recorders having normal heart sounds and a history of type two diabetes, coronary artery disease and a penicillin allergy. What is the most appropriate investigation at this stage that I mean, you know, someone's asked to go through the answer again for the previous one. Oh, yeah. So the answer was c the increased clotting factor production. And the reason for that was um, liver function in chronic heart, heart failure would tend to be impaired um, due to venous congestion that you might get because of the um build up of fluid that's caused. So, um I hope that makes sense and because of a result of that, you would expect clotting factor production to be decreased rather than increased. Uh If that makes sense, um I'll put pull up for this next question. We'll give you some time to read through that and choose that option. So yeah, as most of you has put the correct answer is e transfer us echocardiogram. Um So when it comes to this question or any question that you get, if you notice a patient has a fever and a new murmur that wasn't uh noticed before. So I think in this one, um in this case, it says, yeah, she had recent notes on track from an admission 30 days ago for Car New Angioplasty eight and that showed normal heart sounds. So you know that it's a new murmur and she has a fever. And when you see both of those things together, automatically, you have to assume it's infective endocarditis until proven otherwise. So the first investigation that you want to do in that case is a transthoracic echocardiogram. So, fever, new murmur straight away and you're thinking ineffective endocarditis, uh you want to get an echocardiogram straight away. Um So just a little bit about murmurs. Um, it's useful to learn a little bit about these, keep these in mind. Um, systolic murmurs are more likely to come up, but I would still say it's um useful to look at the diastolic ones as well. Um And the two most common ones that are aortic stenosis and mitral regurgitation. Um So a few different causes. Um so erotic stenosis could be age, a bicuspid valve or rheumatic heart disease, mitral regurgitation, age, rheumatic fever, infective endocarditis, connective tissue disorders. Um There are various know monix um that you could come up with for to help you remember uh the different types of murmurs, one given here, Mrs as uh nice one. Uh nitro regurgitation, systolic. Uh So that should, yeah, you can just help you remember that that's a systolic murmur and that it's pansystolic and then aortic stenosis systolic. So that's an ejection systolic murmur. So, um that would be towards the end of the systolic beat if that makes sense whereas pansystolic is throughout. So like just be another way to remember it. Um One that I used was as Mr Arms and that put the diastolic murmurs in there. So, um aortic stenosis metro regurge um aortic aortic regurgitation and uh mitral stenosis and that again to put it in order of so uh aortic stenosis, ejection, pansystolic for metro regurge and similarly for the diastolic murmurs as well. Um So those four, I would say the key ones to kind of remember, I think systolic murmurs are more likely to come up. Um, when it comes to the two other ones written here that useful to just keep in the back of your mind, tricuspid regurgitation um can because like pulmonary hypertension, rheumatic fever and again, effective endocarditis if a question ever comes up with an IV drug user, um the most likely valve that it's going to be involved in infective endocarditis in that case would be try custard. So always keep that in mind. Um IV drug user tricuspid regurge um pulmonary stenosis. So it can be congenital Turner syndrome, for example, rheumatic fever and carcinoid syndrome, but that's quite um quite unlikely to come up I would say. But so yeah, keep in mind systolic murmurs um and have a look at the dust diastolic ones and tricuspid regurge. Just remember IV drug users and infective endocarditis. Um just quickly to sign it kind of go through some things for useful for the OSK E. So um when you're describing murmurs, there's a few things you want to always be mentioning. So the timing. So where in the beat is the murmur heard. So for example, in the air, a text and also dejection systolic intensity. Um So how kind of loud is a position where, where you're hearing? The murmur always used to um to remember the spots where you're going to hear different murmurs. So for example, the Arctic stenosis, you were here in the Arctic area, mitral, you're gonna hear it at the apex um position of the patient. So that, that applies more to the diastolic murmurs where you have the different special test that you can do to help you here, the murmurs a little bit clearer. So um for example, I'm sure you guys know it better than I do when you, when you're listening in and you ask for the patient to lean forward, I can help you hear it. And that tends to be um the aortic regurg murmur. And then uh the one where you have your stethoscope on their apex, ask them to roll over and that should help you hear it clear and that's the mitral stenosis one. So when it comes to those ones, that's another thing too. Um Just keep in mind um equality, crescendo, decrescendo. So what's it kind of sounds like um radiation? Um Arctic stenosis relates to the carotids mitral regurgitation um relates to the egg zillah. So that's something that can quite commonly come up also in the stem of questions and that can help you identify which kind of murmur is um systemic features. Um You get them in questions and text books and things tends not to be uh so clear cut actually in patient's, but aortic stenosis, a slow rising pulse with a narrow pulse pressure, um and heaving, apex and metro regurge um af displaced apex and third heart sounds. So just keep those kind of things in mind when it comes to murmurs. Um and he will be grand for those kind of questions. Um So same case again, which of the following statements is false. Uh quite a bit to get through there. So put pull up first. Mhm So, um which of the following steps False a blood blood cultures and an echocardiogram are essential for steps prior to staging. This patient is having dukes A B or C disease positive typical organism in one of three separate cultures, new valve, um regurgitation, an echo and a temperature of 38 degrees fails to meet the criteria for definitive i um positive typical organism growth in two of three separate cultures. Plus valvular regurgitation on echocardiography will be diagnostic of infective endocarditis, positive growth of certain streptococcus species may raise suspicion of colonic malignancy and A colonoscopy should be arranged. Organisms growing in blood culture in a positive in a patient with infective endocarditis are more likely to be gram positive and gram negative. I'll give you some time to look over those okay. And there's interest of time we'll just kind of move on with that one. So um the uh correct answer or the statement is false in this case is a um it's just uh in an exam, you wouldn't get a question like this. Um You're you're never going to be asked which of them. It's, you're not even gonna get like a negative question. So asking you wish of these statements are false. That doesn't come up. But I guess it's useful for revision and that kind of thing. But in this case is false. And, and the reason for that is dukes um staging is for colon cancer or not infective endocarditis. So, yeah, just a little thing um going through the other answers. Um So, uh and b we were saying positive tickle organism in one of three separate cultures, new valvular regurgitation, an echo and temperature fails to meet the criteria criteria. So that shit in those, you have one major criteria into minor criteria for infective endocarditis. Um I would say you don't need to know those off by heart and to be honest, just try to keep in mind a few of the major criteria. And normally it's, you can figure out whether patient's got infective endocarditis in a question. It's fairly obvious, you know, don't really need to go into the kind of details of um the specific criteria for infective endocarditis, but just for this question, because there will quickly talk about it. Um So uh for a definitive diagnosis, technically, you require two major uh criteria or one major and three minor or five minor criteria. Um So it's just a technicality really. Um And then in question three, so that shows uh the two um two major criterias who got positive typical organism growth seen in two or three cultures and the new valvular regurge on echocardiography. So that's two of the major criteria. And if you see those two, then it's infective endocarditis. Um Option D, that is true. Um So, uh for example, uh strep bovis, if that enters bloodstream, um that or well, that can enter the bloodstream via uh colonic malignancy. So, and that can then cause infective endocarditis. So, if you ever see strep bovis, a colonoscopy, it needs to be arranged because you're suspicious about um malignancy in the colon and option D. That's true as well. Um uh Strep streptococcus and staphylococcus species are um the most common cause of infective endocarditis with about 70% of them being the case. One last cardio question. Um Same case, uh blood cultures come back positive and three of three with staph aureus sensitive to methicillin. Um echo echocardiography confirms mitral regurgitation. What is the most appropriate management for this patient? Give you a chance to answer that. All right. So the correct answer for this question is D um So uh a little thing in this question, she has a penicillin allergy. So you obviously don't want to be giving her any kind of penicillin. Um And that's why D is the correct answer for this question. Um So four weeks is the right length of time that you want to be giving antibiotics for. You want to treat it quite aggressively. Um And because of our penicillin allergy, you want to be using triple therapy or vacuum izing gentamicin and oral ref am person. Um uh to treat the infective endocarditis. Um uh in terms of option A, you don't want to discharge her, she requires admission in IV antibiotics and B is incorrect because she's allergic to penicillin. So can't be giving her that. Um And a regular course. So c is mentioned the regular course of oral antibiotics for prophylaxis. Um So that used to be a thing, but it's no long, no longer recommended. So you don't really give antibiotics for prophylaxis anymore. Uh D was the correct answer and e um uh short course of treatment for two weeks, obviously. No, because um she has uh effective endo productive with the staph aureus. So you want to be treating that for at least four weeks and you can use a short course of treatment of two weeks with a heavy antibiotics um for patients who have certain types of strep. So I think strep Bovis with one and strep of very dance to the other. Um under certain conditions, you can kind of be using that, but you want to be careful about that because normally infective endocarditis, you treat quite aggressively. Um and uh useful thing just to remember if in the question, it mentions the patient's have a prosthetic valve valve in their heart. Um That means they would, would require a longer period of antibiotics. So it would probably be longer than four weeks. Just a little thing to keep in mind. Um, what would be the management if she wasn't allergic? So, I, I think you would use, um, an IV penicillin, um, to treat and again, you would be treating for four weeks aggressively, um, in the similar way that you, that, um, you would, you, that we've treated here in this answer. So, yeah. Um So that's the cardio section done. Um, uh If you have any questions, just pop them into the chat, we'll take a five minute break now and if you guys want to come back at quarter past and we'll get started with the respiratory questions. It's all right. So her short break got quite a bit to get through. So we'll crack on and try and get through as quickly as we can. So, starting off with another question, 28 year old woman presents to her GP with two month history of shortness of breath on exercise. She also complains of cough and a wheeze which is worse that worse at night on, on saltation, you notice a widespread, widespread wheeze, which of the following is not a recognized trigger of the likely condition. Get the pull up again. Yeah. Yeah. Yeah. Uh huh. Um Yeah, so we're a little bit split. It's pretty is exactly 50 50 between um uh A and D. Um So the correct answer is actually a in this case. Um uh It's just a little trick on words. They're um it's beta blockers which are contraindicated in asthma, not alpha blockers. Um And yeah, hopefully you guys were able to figure out that she's presenting with asthma there. Um Cold air and Rhinovirus, um common triggers of asthma and aspirin actually is a trigger of asthma as well. Um can lead to an exacerbation. So that's just a little point useful to keep in your mind. Question too. Um Same patient, what is the most appropriate management at this point? Start? Cool. So the patient has just presented to you, what would you, what would be the next thing that you do in this case? Mhm So a little bit split on this one. Um Most people have gone for a um the correct answer. The answer actually in this case is um d uh starting a short acting beta agonist in a trial of an I C S. So, um and when it comes to asthma, one of the best ways to just diagnosis, try and treat it and see if the symptoms get better. So, immediate trial of treatment with Sabah and an inhaled cortical steroid can um be formed in this case because it's from the way the patient is presented, you think it's quite likely that asthma is a diagnosis. So, um when they're presenting with one or more of obese, breathlessness, chest tightness or cough, then you've got high probability of asthma So you don't want to be waiting around really doing any tests or anything. Um, you want to just diagnose that and trial the treatment and if they work, then your diagnosis is correct. If not, then maybe you need to reconsider at that point. Um, and especially symptoms that you want to keep an eye out for if they're worse at night, uh, they respond to exercise, cold air on an allergen. Um, if you have a past medical history or family history of atopic conditions or asthma itself, and if the symptoms came on after a beta blocker or an aspirin, uh was given, um, those kind of things would point you towards direction that asthma is a very likely diagnosis in that case. So as soon as you see that, as soon as you think the asthma is very likely diagnosis straightaway, you want to start the treatment. Yeah. Um So this is just the same guidelines which kind of go through this a similar kind of thing. Um So if you think there's a high probability of asthma, you want to start treatment straight away, as you said, um, if you don't have a good response to that, um, that's when you start to do the spirometry and Broncodilator testing. And at that point from there, you should be able to get uh better understanding of whether asthma is likely or not and what are the appropriate treatments at this point. Um So yeah, just useful to have a look through that. Um So that flow diagram sums it up quite nicely. Um So question three patient returns to the G P two months later complaining that the treatment is ineffective. Uh What is the next step the G P should take? Uh We're considering also at this point that she the diagnosis of asthma was correct. Mm Yeah, you start to pull. So in this case, the answer is as most people put check inhaler technique and if it's correct, uh laba, so that's the correct answer on this one. Um And someone also mentioned in the chat um about the nice uh nice guidelines. Um Yeah, I think those are the right ones. I think these slides might be a little bit old. Um If this is what you've been taught and these are the most up to date guidelines. And I would go by that. I remember last year we also had a few problems with understanding what was the correct uh sort of answer when it came to investigations and things like that when with asthma. So if these are the kind of guidelines that you've been taught to use, then I would stick with that and not what we've said here. Um Yeah, and yeah, we'll go on with this question. So, um one of the first step, if we look at the answers here, so it in the correct answer, it says check inhaler technique and if correct, add a lava. So the first thing whenever a patient with asthma comes back and the reporting that their symptoms have got worse or they've come back following treatment. The first thing that you want to check is whether their inhaler technique is appropriate. If, if you find that it's not, then, you know, adding another drug or increasing the dose isn't really going to make a difference because they're not using the inhaler in the correct way. So straight away, if you ever get question and, and it comes up, what is the next step? The first thing should be to check the inhaler technique and also the adherence, making sure that they're taking their inhaler regularly as they should. Um And then once you checked those things, then you'd consider stepping up on the pyramid that is kind of shown here. Um So going up the kind of steps you're adding on different therapies or increasing doses um at various points. Um It's a good idea to have a look through this, keep an idea to get an understanding of which steps you add drugs, which steps you increase doses. Um And I know different places, kind of say slightly different things. But if you keep the general idea in your head, um you should be okay. Um And also another thing is if a patient is being reviewed and they've not had any symptoms for a while, you can consider stepping them down, um the ladder as well. So it works both ways. Mhm. And, um, if you, if you're stepping a patient down, they have to have shown that they've had good control of their asthma for at least three months. And then you can try out that and see how that goes. Um, so a 20 year old woman visits her GP with worsening breathlessness and we, she has asthma and takes beclomethasone and salbutamol inhalers. Her pulse is 1 20 BP, 102 over 72 respiratory rate. 22 oxygen stats, 94% widespread Xperia Torrey Wheeze and peak exploratory flow rate of 260. Her predicted is 420. Uh which feature of her presentation means she should be referred immediately to hospital. Give you a chance to answer that. Okay. So, um we're reasonably split with B and D being the most common answers. Um In this case, the correct answer is D um the reason for that is their policies 120. Um And when we're looking at acute exacerbations of asthma and you kind of split it up into moderate acute, severe asthma or life threatening. Um And there's a few different parameters that you should roughly be aware of. There's um the main ones you want to be thinking about are the peak expo exploratory and flow. So 33 to 50% of predicted. So in this case, um should 260 the normal was 420. So that would roughly I think be around 60%. So it's not within that kind of range. So you wouldn't classify it as acute, severe asthma and obviously not, it's not life threatening. At that point, the um the only aspect of her uh vital signs and things that we're uh that would make you want to get her to hospital was her heart rate, which was 100 and 20 and the cut off for that is 100 and 10. So at that point, you're considering admitting the patient to hospital. Um There's a few different ones to be aware of. One thing that I would point out is um the normal P C P A CO2 in life threatening asthma. Um Nor um you might expect that uh in life threatening asthma, it might be um a low for example, or perhaps raised, but often it is normal and that's quite a bad sign. Um If you come across that because that means that the patient is tiring and they're unable to blow off CO2. So in that case, it could, it would either be normal or raised. And if you notice that, then um that's a life threatening or even near near, near fatal last month. So definitely want hospitalization for that and I want to be getting the patient uh appropriate management. So just keep an eye out for those things. Um And they can help you figure out what kind of management you need to be doing. Um But yeah, as I say, try and roughly learn what the kind of numbers are. Um uh you'll be fine with those. Um question five, the same patient. What is the most appropriate first line management for this patient? You want to try to see? Uh um Yep. So as most people said, the answer is he gives salbutamol by option driven nebulizer. Um Yeah, so someone mentioned uh prednisoLONE would be first line. Yeah, that's also, but just out of the options here, uh Nebulizer would be one of the first things that you'd uh you'd give uh in reality, I mean, you'd probably be giving a lot of the stuff at the same time if a patient presented and they were quite unwell. So, yeah, but yeah, prednisoLONE. Keep that in mind as well. Um So acute asthma management. The another acronym there. Oh Shit. M so oxygen you want to be taking uh targeting sat of 90 40 98 salbutamol by a nebulizer, hydrocortisone or, or a prednisoLONE, as we said. Um And uh I Potro Priam can be added as well. And then if once you've done all of those and there is still no improvement at that point, you want to initiate um theophylline and magnesium sulfate, but those are done by a senior. So, yeah, initial management involves oxygen's albuterol nebulizer and prednisoLONE generally uh Ibutropian comes after that can also be given and then you have the, uh, the theophylline and magnesium sulfate as well. Um, investigations. Yeah, just ones that you'd expect, uh, bedside operations very important. Always have a look at those peak Xperia Torrey flow A BGS and standard blood chest X ray E C G. So just the standard things that you'd expect okay is to, um, 78 year old lady with a 40 pack year smoking history. You had a productive cough and breathlessness on exertion, just felt increasingly short of breath over the last six months on hurrying or walking up hill, which are the following results is suggestive of a diagnosis of COPD in this patient. We'll start pulling, give you some time to answer that one. Have a look through the options. Come on a couple more seconds for that one. Yeah, a little bit split. But um the correct answer is see in this case or an F E V one less than 80% of predicted and an F E V one um FEC ratio of less than 0.7. Um Yeah, so looking at the pulmonary function function test, always very useful to keep in mind um to understand whether it's a obstructive condition or restrictive. And for now, we'll look at COPD, I think later on, we come on to the restrictive ones. Um So generally you can kind of work these out. Um You don't have to kind of go out and remember each one and what would happen? Um just by thinking about the condition and what would likely happen. So, and COPD uh the F E V one, you would expect that to be decreased um as a result of uh uh the condition and normally the cut off for that was around 80% as was said in the question, um uh F E C as well, you'd expect that to be uh decreased. And so then when you look at the F E V one F B C ratio, you would expect that to, again be decreased because both of those things would be decreased. You wouldn't be able to someone with COPD, they wouldn't be able to exhale as much air in the 1st, 2nd as someone with normal lungs. And when, when totally exhaling, they wouldn't be able to exhale as much as someone with normal lungs again. So, um, I think that falls uh pretty nicely. Um Then a couple of other ones, total lung capacity would be increased in COPD. Um due to the emphysema and drop the lungs, um taking up a little bit more space and not being as elastic and T L C O. So the transfer factor for carbon monoxide that would be decreased. Um uh in COPD and the K C O, um which kind of just shows overall gas transfer would be reduced as well in this case. But, um, those two aren't so much as important. I would always just keep in mind the F B one and the FEC those are two most important things transfer. You understand, like what the what would happen to both of those in a patient who is presenting with whatever lung condition it may be. And then from that, you can work out what would happen to the F E B one F E C ratio in that case. And yeah, this is just again, going through the lung volumes and capacities. I won't go through this in the interest of time. But yeah, just keep those in mind um case to question to spyrometry. Confirm COPD and G P discusses treatment options with the patient with the patient which is single most effective management and COPD. Um I'll stick pull on, I'll make this a quick one and yep, everyone's put the same answer. So smoking cessation, um number one most important thing in COPD for the first thing that you do is you get them to stop smoking cigarettes. That's the best and most effective treatment that is available um in COPD. So just going through COPD COPD management quickly um three things for every patient with COPD that you want to remember smoking cessation, obviously, number one, parliamentary pulmonary rehabilitation and something that's quite easy to forget. They get annual influenza and a one off pneumococcal vaccination. So that's useful to remember. And then when we go into the kind of inhalers that they use um first line of Sabah or Osama. And then um at that point, if those don't work, you'd go onto adding various alternatives um based on a few different things. So if they have asthmatic features or features, that's just steroid responsiveness that would change um the kind of options that you would use in that case, but generally you'd be using some combination of a lava Allama and an eye CS. And again, it's a step wise approach. So if one step isn't working, you move onto the next one. Um Yeah, so just keep those things in mind. But smoking cessation, obviously, number one most important thing question for um uh I think this is a 66 year old gentleman with the COPD. You presents G P increased, wheeze, breathlessness, strike off, you can speak in full sentences. The pulse rates, 95 BP, 135 or 72 respiratory rate, 20 sets of 95 temperature of 37.4 and he has a diffuse xperia Tory. We's um what is the most appropriate management at this stage? You know, start the pole? Okay. Okay. So we're pretty split on this one. Um sort of between A B C and E. Um In this case, the correct answer would be um uh see oral prednisoLONE. So in this case, person has got an exacerbation of the COPD. Um And you suspect that it's probably non infective. Um He doesn't have a fever and he's not kind of coughing anything up. So there's nothing really to suggest that antibiotics might be um necessary. And just by looking at those um kind of uh vital signs, you, they're not grossly deranged, so you can sort of manage them in the community. You wouldn't need to uh refer him to the hospital. Um Option B would be correct if the patient had signs of infections. Um So things like increased sputum um or a change in the color of the sputum or a new change on the X ray or increase uh elevated CRP. So those kind of things would point to a words, an infection and in that case, you would prescribe an antibiotic along with prednisoLONE. Um uh in terms of admitting to hospital, um if the patient's uh sats were very low, so generally below 88% um they kind of had respiratory distress. So they were very tight Hypnic, weren't able to speak in full sentences, uh that kind of thing. So then you could refer them to a hospital, but this patient didn't have any of that. So you can be managed in the community. And in terms of the chest X ray, you wouldn't really need to be doing that in this case. Um because there's nothing in the history or his observations that would suggest that he might have pneumonia or pneumothorax or anything like that, that would require a chest X ray. So I hope that all makes sense. Um question 5. 65 year old woman has an infective exacerbation of COPD. Uh, our temperature is 37.8 pulse rates of 100 and eight BP, 100 or 75 respiratory of 26 ocean sats, 88 breathing 15 liters of oxygen by non rebreather mask. She is alert some investigations of some AB GS are given there and the question is, what is the most appropriate next management option? So I'll let you have a look at the A B G and I'll get the pole up. I'll give you some time to go through this one. Yeah. So most people have gone with e noninvasive ventilation, which is the correct answer in this case. Um So I think you can tell it's patient's quite unwell and if you look on there A B G, um, it shows that the, um, they have an acidosis is and uh, yeah, an acidosis. So that's one of the, um, one of times you start to consider non invasive ventilation for this kind of patient. Um So in terms of acute COPD exacerbations, this is the kind of management. So oxygen start on controlled oxygen 24 to 28%. Bio ensure E mask. And always remember with oxygen in patients with COPD, you want to be targeting SATS between 88 92% and you don't really want to go over that because at that point, you'll start to lose their, uh respiratory drive, which is by um which is influenced by the sort of uh increased CO2 that they would naturally have. And once you start to get more oxygen at that point, it gets um quite dangerous for them. So that's always something important to keep in mind and you want to titrate that according to the A B G results. Um nebulas, salbutamol similar to asthma and plus or minus hypertropia. Um um oral prednisoLONE, 30 mg plus plus or minus antibiotics. Again, if you were considering an effective exacerbation and then noninvasive ventilation be looking for ph of less than 7.3. So an acidosis and PCO two of greater than six. Um Yeah. Um So case three, um A 78 year old man recovering from an open reduction, internal fixation of a fractured right tibia three days ago, complains of shortness of breath, localized and increasing pain at the operative site. Right calf is swollen compared to the left calf with pain on Dorsey flexion. He has a history of angina and is currently receiving treatment for prostate cancer. His observations, heart rate of 100 and four BP, 135 over 85 respiratory of 26. Uh oxygen sats of 89 on room air temperature of 37.5. You order some bloods including FBC quad screen cardiac enzymes A B G E C G chest X ray and starting on oxygen. Which of the following is the most likely E C G change. Um, so those are the options that will pull up and I'll leave this up so you can read the case. Yep. So most patient know most people that answered that one quite quickly. Um So yeah, the most likely diagnosis in this case is a pulmonary embolism. Um, he's recently had surgery and he's complaining of shortness of breath. So the first thing you think about is A P in that case, and in terms of what is most likely changed that you're gonna find on the E C G, um is actually be sinus tacky cardio. And I think a lot of textbooks and things kind of say this uh deep s wave and lead one and Q wave and lead three and an inverted T wave and lead three. Um It's kind of a textbook thing and it's not really something that you tend to see more commonly sinus tachycardia is the only thing that you're going to find on an E C G with a patient who has a pulmonary embolism. Um So, yeah, um it's roughly only in 20% of patient's that are meant to have that. Um the S one Q three T three, but in practice, I feel like it's even even less. So sinus tachycardia is the most likely thing that you're going to find. Um And this is kind of showing the S one Q three T three that you might see. Um and also in the C C G, there's um some evidence of a right bundle branch block as well. Um So, yeah, move on to the next question. Um Given the clinical history, what is the most appropriate diagnostic investigation for this patient? Um Yeah, so most people have gone with B C T P A and in this case, that would be the right answer. Um So one thing when it comes to p questions, um thinking about the well score can be quite useful. Um Generally, I would say you don't, uh personally, I would say it's easier to just kind of look at the well score, understand what are the kind of signs that it gives points for rather than memorizing it, sort of word for word and learning exactly how many points you're getting for various things. Um I think generally when it comes to these kind of questions, you can understand just by reading the scenario given to you, how likely it is the patient has A P. Um It's pretty um you know, you only have to score four points to be able to get uh CT P A. And if you think straight away with clinical signs and symptoms of DVT, you're scoring three points. So it's pretty likely at that point that you're going to go over four. So um uh is worth keeping that in mind and that could be a useful tool to help you figure out what is the most appropriate investigation. If it comes across, it's very likely that patient has a P C T P H straightaway is uh correct option. Um If they do score below four, that's when you do the D dimer before you do the CT P A. Um if the D dimer comes back negative, then um of course, you, you move on and you consider a different diagnosis, but it's positive, then you move on to doing a CT PA and going from there. Um uh One little thing here, if you suspect a patient has A P, you don't wait around straightaway, you give them anti coagulation while you're waiting for the investigations to be completed. So, um first thing that you do patient comes in suspect p you would give them uh an anti coagulant. Um and then work out the wealth score and go from there. Um So what is the most appropriate management in this patient? Okay. So we're a little bit split between A B and D on this one. Um So in this case, I would say the correct answer is do the oral Apixaban. Um So uh as for a IV alter place, um you would use thrombolysis if the patient was in cardiogenic shock. So I think if we look back at the case, I don't think there was anything to suggest that um he was in shock, his BP was normal. Um And yeah, there was nothing really to suggest that he was in shock there. So if of course, the patient was hemodynamically unstable, at that point, you would do thrombolysis, that would be the most appropriate management. Um therapeutic low dose molecular uh Heparin is uh that, that would be an option, I think um because these flights are a little bit older, I think uh this one was the correct answer. Um I think in the, in the question, it mentioned that the patient had active pro prostate cancer. So in the past, it used to be that you would give Heparin um to patient's with the active cancer. But I am, I think recently that was changed to allow uh to say that do X can be given. So in this case, oral Apixaban would be, would be the correct correct option. Um As for surgical thrombectomy that tends to be inpatient to have sort of recurrent chronic peas. Um But that is also a management option there. Um So yeah, p management, humanlike, dynamically unstable thrombolysis with IBL to please um they're human, dynamically stable. Oral picks. Eban is uh first choice or river oxygen um important with these kind of things. Uh You'd uh be careful with their use when we're talking about the extremes of weights under 50 kg, over 100 and 20 and also in renal impairment. So if they're E G F R is left in 15, you would probably, you'd rather use heparin in that case. Um And yet, as I was saying, it's also used in active cancer. Now, um unfractionated heparin, it's reversible and used if there is a high risk of bleeding. So, you know, that's one of the advantages of it. I think a lot of the dogs now, I do have um things which are allow them to be reversible as well. So um that's slowly come into play as well, uh length of treatment. So you want to consider continue their anti coagulation for a certain amount of time. So if the, if the pe was provoked, so as it was in this case, the patient had surgery, so if there's a risk factor that would lead to the patient having a P, then you'd be looking at a shorter time of anti coagulation. So we'll be looking at three months. If it was unprovoked, there was no obvious cause for the PT, then we're thinking about it being for a longer period of time, six months, um, active cancer. So again, six months and then as long as the cancer remains active. So again, there's no longer uh longer uh timescale there. And if recurrent peas, then we're looking at lifelong anti coagulation case four. Um, you're the F two in any and you're asked to a, a 67 year old man who has been brought in by his wife, she's worried because he was acting confused and had a shaking fit and was having difficulty catching his breath. She also tells you that he had a productive cough and generally been generally been feeling unwell. Regular medications include simvastatin and prednisoLONE for polymyalgia, rhuematica. No recent hospitalization smokes 10 cigarettes per day for 50 years and was a taxi driver for 40 years. Uh Some observations, heart rate of 100 and 10 respiratory rate of 32 BP, 110 over 65 02 sats 93 on room air temperature, 38 chemo globe in 100 and 30 white cells, 20 urea eight and raised CRP. So I think the hemoglobin is normal, white cells are raised, the urea is normal and CRP is raised, etcetera. Um I don't know, sorry, the urea is raised as well. Um On examination, uh you know, he's disorientated to time and place um dullness to percussion at the right base, bronchial breathing at the right base and crackles throughout. Expect. He has pneumonia and a range of chest X ray and send the sputum sample to the lab where is quite a lot in that. But let's see. So key things that you want to take away from this history. So patient has confusion. He had a shaking fit. I think it can be quite easy to mistake this as a seizure, but I think it's more likely that he's had rigors due to the due to the fever there. Um It's got shortness of breath, productive cough and generally just feeling unwell prednisoLONE for polymyalgia, rhuematica. So it's getting the long term cortical steroid and that's obviously going to suppress the immune system making it more likely to pick up infections. Um, and, and all that thing, all the stuff that we said to Kartik to get the Auto Sat's or low pyrexia will high white cell count, high urea, high crp. Um, and then on examination had dullness, bronchial breathing crackles and he's a smoker, which is a risk factor for pneumonia. So I think it's if you see any of these things, you want to be thinking pneumonia in the patient. Um So question one, uh what is the curb 65 score? Um I won't go through it and I won't put this one up as a poll because it has the answer there anyway. But curb 65 very useful. Always remember it will come up in exams. Um So stands for confusion. So this patient was confused, disorientated time and place urea. Um So if the urea is greater than seven and in this case, it was eight. So he's going to score a point for that respiratory rate 32 that was raised. So, and I think it's over 30. So he gets another point for that. His BP was fine actually. So he doesn't score for that and his age was 67. So over 65 is going to score another point. So he would have had a carb 65 score of four and So he would have been the correct answer in this case. Um Yeah, so that's the things uh you would use um to assess confusion. I mean, you can use official um sort of cognitive assessments but normally in, in questions and things that would just say they're kind of disorientated time in flux like you did in this one. And for the BP, systolic under 90 diastolic under 60. So just keep an eye out for that in terms of what the scores mean. So if it's zero or one, then they have a, it's a low severity and that can kind of be generally, could be treated at home. And if we're scoring to, that's moderate, probably want to keep them in hospital and treat them in hospital and 3 to 5 is high severity. So, um, definitely want to keep them in hospital. Uh question to what is the most appropriate management? Uh Put this pull up. Um, um I realize it's getting close to eight o'clock now. So you guys are welcome to leave if you, um, feel like I think Lucas will put the feedback form in the chat. Um, otherwise, um happy to continue and we'll go through, we've got a couple more cases to go through and I'll try to go through them as quickly as possible and hopefully get it done within the next sort of 15 or so minutes. And, but if you need to run, that's understandable. But yeah, thanks for coming along and please fill out the feedback form if you could help us out. Thanks and, um, okay. And as for this question, um, uh, so most people have gone for D which is the correct answer in this case. Um So we know that from the previous question that this patient has severe pneumonia, so he's going to need some pretty extensive treatment. Um, for option A, that would be appropriate treatment if it was moderate uh curb 65 pneumonia. Um For option B, you don't want to be discharging this patient obviously because he has uh severe pneumonia, uh neurology, shaking fit. So as we said before, unlikely to be a seizure, uh probably just triggers due to the fever. Uh The was the correct answer. Admit to straight to I see you. Um you should try treatment first um and obviously make the ICU staff aware, but you want to try Steve treatment first and go from there. Damn. Mhm. Mhm. Okay. Uh management of pneumonia, oxygen fluids and antibiotics pretty straightforward. Um Those are the mainstays. Um And as we were saying before, if they score law, they can be treated at home if they score two or above, uh they should be treated in hospital with antibiotics. Amoxicillin, Clarithromycin are two options are normally used and if they score more than that three or more, then same thing again. Uh but we want to be using IV co Amoxiclav IV Clarithromycin and assess the need for admission to ICU. Um, uh, the results from patient sputum came back positive from the lab. And what is most likely causative organism? Put the poles up or try and speed through these polls and, uh, a little bit quicker. So, we're not here for too long. Mm. Yep. So, um, most people have gone for the right answer, which is a Hemophilus influenzae. Um, if we don't, I thought there was a slide there. Um I think the uh okay, well, we'll come back and talk to talk about the different uh organisms uh after we do this question as well. So 40 year old businessman recently attacked from work return from work conference in Turkey spent a lot of his time in air conditioned conference rooms has a dry cough and reports, multiple episodes of vomiting and loose stools. Um heart rate of 90 BP, 1 30/90 with surgery. It 20 for uh sats are fine and temperature of 37 what is most likely cause of organism of this patient's symptoms? Quickly put the pull up for that one and yep, everyone's put the right ones who legionella as soon as she air conditioned air conditioning, legionella is the option. Uh Yeah. So this is like I was looking for um community acquired pneumonia. So yeah, it's useful to differentiate between community acquired in the hospital acquired just because the most likely organisms are slightly different between the two. Um, it's quite common exam question. It's always useful just to remember the differences. So community acquired pneumonia is little to no written contact with the healthcare system and hospital acquired is over 48 hours after admission. Um, it's a little bit of a gray area, the exact timing, but we'll go with 48 hours for this case. Um, so for community acquired pneumonia, the the common options or less there, haemophilus influenza and streptococcus pneumonia being the most likely. Um, if it's an elderly patient is almost always the hemophilia, uh hemophilias influenzae in young patient's mycoplasma pneumonia tends to be um uh slightly more common as well. Just look out for in patient with michael plasma, they would show their blood test would show a hemolytic anemia. Um So that's something to keep an eye out for and could be a little bit of a clue in questions. Um And yeah, just a list. There are a few other other organisms. Um, one thing to keep in mind, um, staph aureus is more common in community acquired pneumonia following influenza. So that's, uh, that's something that comes up a few times in uh exam questions. So if a patient has influenza and then they develop pneumonia, staph aureus is most likely organism, we're going to case 5, 25 year old man presents with a cough, shortness of breath on exertion, dry eyes and a red tender, red tender lumps on his shins. Um after looking at his chest X ray, what is the most likely diagnosis? Yeah, we're getting there. We're almost done. So, hopefully it shouldn't be too much longer. Mhm. Mhm. Yep. And then most people have put their, the correct answer is sarcoidosis. Um, so with sarcoidosis, the main thing on chest X ray is that you're looking for is the bilateral Hiler hilar lymphadenopathy. And so you can see that on this chest X ray, there's kind of more pacification around in the hilar kind of areas. And that's yes, hilar lymphadenopathy, um uh in sarcoidosis in chest X rays by the stage that it is, you would see different things. So in stage ones, you would see the bilateral hilar lymphadenopathy. In stage two, you would also see that, but you also see infiltrates and patient would have more kind of symptoms that you have a cough, shortness of breath as is in this case. And stage three, you would have the infiltrates, but you wouldn't have the bilateral hilar lymphadenopathy. So that wouldn't be present on the chest X ray, you wouldn't be able to see that. So that sometimes if you think sarcoidosis is the most likely option and it's not the chest X ray doesn't show that bilateral hilar lymphadenopathy. Just remember that it could be a later stage in which you might not see that. And then stage four tends to be pulmonary fibrosis at that point. Ok. K 6 71 year old man presents a G P with progressive breathlessness and dry cough. He denies orthopnea hemoptysis. We've or chest pain on examination. G P notes tar standing on his right index finger finger clubbing and find by basal late inspiratory crackles. He's referred to the R I E and undergo spyrometry. Chest X A chest secretary and HR CT results FPV, one is reduced. FEC is richest as well. Uh FPV one FEC ratio is greater than 90%. And the chest X ray shows subpleural reticular shadowing. Hr CT suppler on basically dominant reticular pattern, honeycomb cysts and traction bronchiectasis. Uh So the question is given the most likely diagnosis which of the following is not part of the management of this condition. Mhm. Um Yeah. So a little bit split on this one. Um So the correct answer and this case is be um all of the other options are part of the management. And so the most likely diagnosed in this case is uh pulmonary fibrosis uh be used to be. So the prednisoLONE azaTHIOprine and N acetylcysteine used to be part of the management of pulmonary fibrosis but no longer the case. Um um So, yeah, that's that one. Um I'm just going back to these kind of uh spirometry results. Um So those are the things that you would tend to see with a restrictive condition. So it's the F E B one could be reduced and the FEC could also be reduced. But when you look at the ratio, it would actually uh tend to be uh either normal or raised. Um So with the COPD, if you remember before, we said I would be under 80% in pulmonary fibrosis generally would expect that to be over 80%. Um So that's a, a useful thing to keep in mind when you're trying to differentiate between the two. Um uh interstitial lung disease is. So that's just something to keep in mind trying. Uh sometimes you, you might see in the questions, there'll be something which sticks out. So for example, ask pissed osis. Um you'd find that they're a worker on maybe a shipyard or something. So it had been exposed to that. Um Generally the most common is idiopathic pulmonary fibrosis, but it's always used to, to keep in mind some of the little triggers and things that might be mentioned in the stems of the questions. Um So for the rest of the questions, I'm just going to uh speak about the question and just give the answer rather than going to the polls just in the interest of time because I know we've ran over quite a bit. Um So K seven, what is this chest X ray? So, so in this one, the correct answer is um e a left sided pleural effusion. And if you still look on the chest X ray, I think that's pretty clear there's a lot of fluid, very uh big area of a pacification on the left hand side, um uh reduce the long volume there. So, uh if you see that as a pleural effusion um quickly just to go over trans you date versus actually, they can be something that's uh useful to remember and differentiate between the two. You could get a question where they talk about and aspirate and you have to figure out what the likely cause might be. Um So a transit date tends to have low protein and the causes for that tends to be heart failure or liver failure. And uh today, it tends to have high protein and that tends to suggest a malignancy. So just always keeping those in mind that should help you um work at the cause. There are a few other causes listed there, but those are the big ones. The failures tend to be transit dates and extra dates tend to be caused by the malignancies. Um Case eight, reviewed the chest X ray of a patient who presented the shortness of breath. What is the diagnosis? So, in this case, um it would be a left sided pneumothorax. It's quite hard to see on this one. But if you zoom in, you'll notice that there's an area on the left hand side up at the top where there are no lung markings. Um So that's what you want to be looking out for that the lung markings go right to the word right, to the edge, right to the borders of the lung fields. If you notice an area where there isn't um that, then you want to keep that in mind and uh you know, pick that up and realize that that's probably a pneumothorax. Um they can be quite small. So you don't, you want to look closely and uh look properly. Um So next question really is report spread a large left side in pneumothorax um which is greater, greater than 15% of the hemithorax. How will you manage this patient? Um So, in this case, needle aspiration anteriorly in the second intercostal space, midclavicular line. Um So there's slight differences in management. This is a very useful uh diagram which goes through and the different um management options that you would do. And a lot of it depends on the size of the area of the pneumothorax. And what the kind of causes are pneumothorax. I won't go through it all in the interest of time, but worthwhile having a look through that case. Nine, what is the most likely diagnosis in this case? Um I think it should be fairly obvious there's a lot of uh markings in the lung fields. Pulmonary metastases is probably most likely um lung cancer. So, symptoms and signs cough hemoptysis, pleuritic pain, Horner syndrome, uh superior vena cave obstruction, weight loss. So the kind of standard things that you would expect um when it comes to that as for Horner syndrome and SPC. Oh, so with Horner syndrome. You'd see ipsilateral partial tosis, um, may osis and, um, sweating on one side of the face. Uh, as for SPC. Oh, uh, the main sign for that is you'd get facial and upper limit Dema so their face would be quite swollen. Um, and we're quite marked and quite easy to notice that, uh, different types of, uh, lung cancer, squamous cell is most common and then you have adenocarcinoma, small cell and large shells and in terms of parent neoplastic syndromes, just worthwhile knowing a little bit about them. Um And the different ones that can be caused by each type. So, uh squamous cell hypercalcemia, finger clubbing, hypertrophic, pulmonary osteoarthritis, pathy. So worthwhile keeping that kind of things in mind when you, whenever you see that if a patient comes with sort of the respiratory signs, along with some of these signs, you'll be thinking of squamous cell cancer as for the small cell, there's a few different ones here, SIADH. Um So with that, you would kind of notice a hyponatremia ectopic ACTH. So Cushing's adrenal hyperplasia, um It's kind of thing, you'd be thinking around that cerebellar syndrome, Olympic encapsulitis and Lambert Eaton syndrome with that you would uh that's kind of an anti antibodies are attacking the neuromuscular junction and you get kind of weakness and things like that. Um But that is everything that we've got uh lined up for this. I'm sorry that you ran over a little bit, but um, you have any questions, pop them into the chat. Otherwise I think, look as it popped the feedback form into the, into the chat. So very much for, uh coming along. Yeah. Mhm. Thank you very much Osama. Um, just before you leave, we would really appreciate if you could feel that the feedback form which I fed up in the chat, uh, on completion, you'll gain access to the catch up content and you'll be extremely helpful for us in improving subsequent sessions. Um If you don't really know, we've still got formal sessions throughout the week at the same time, every day from 6 p.m. to 8 p.m. So be sure to register. I've popped a link to the Facebook event page in the chat for registration details and make sure to click, going to receive upstate to remind us otherwise. Thank you very much for joining and have a great evening.